BACKGROUND:Pain in trauma patients is frequent and associated with adverse physiological and psychological outcomes. Despite the recognized importance of early and effective analgesia, prehospital pain management remains insufficient in a substantial proportion of cases. Emerging evidence suggests sex-related differences in analgesic treatment, with both patient and physician sex potentially influencing therapy. This study investigates whether specific physician-patient sex pairings, alongside clinical and operational factors, are associated with the efficacy of prehospital pain management and explores how these factors interrelate to contribute to inadequate analgesia. METHODS:We conducted an observational cohort study of trauma patients treated by a Swiss physician-staffed Helicopter Emergency Medical Service between September 7, 2020, and July 24, 2025. We included patients with a Glasgow Coma Scale (GCS) ≥13, a National Advisory Committee for Aeronautics (NACA) Score 3), persistent untreated pain, and pain reduction. RESULTS:Of the 43,024 prehospital missions analyzed, 5168 met the inclusion criteria. The cohort was predominantly male (3097/5168; 59.9%); the median age was 47 [29-62] years. Extremity trauma was most common (3514/5168; 68%). In 32.2% (1663/5168; 95% confidence interval [CI], 30.9-33.3) of cases, analgesia was insufficient. While male physicians achieved greater NRS reduction (Coef. 0.20; 95% CI, 0.12-0.28), male patients reported less pain relief (Coef. -0.13; 95% CI, -0.21 to -0.05). Higher initial NRS scores (odds ratio [OR] = 1.45; 95% CI, 1.39-1.51) and omission of analgesics (OR = 5.70; 95% CI, 4.54-7.15) were associated with insufficient analgesia. The use of a combination of opioid and ketamine was associated with improved analgesia (OR = 0.69; 95% CI, 0.58-0.83). The greatest pain reduction was observed with ketamine or combination therapy. The median ΔNRS was 5 (interquartile range [IQR] 3-6) for ketamine and 5 (IQR 4-6) for combination therapy. CONCLUSIONS:In this large cohort, we found sex-related differences in patient-reported analgesia: male patients were more likely than female patients to report insufficient analgesia. Treatment by male physicians was associated with better patient-reported analgesia. Ketamine and its combination with opioids were associated with greater patient-reported NRS reduction compared to opioid monotherapy in a prehospital setting.
BACKGROUND: Postoperative delirium is a frequent and serious complication in older patients after surgery, particularly following hip fracture repair surgery, with an incidence of 10% to 55%. This study investigated whether goal-directed intraoperative blood pressure management could reduce the incidence of postoperative delirium in older patients undergoing hip fracture repair surgery. METHODS: In this single-center randomized controlled trial, 188 older patients (over 65 years) scheduled for elective hip fracture repair surgeries under spinal anesthesia were randomized to either goal-directed arterial blood pressure (ABP) group or control group. The goal-directed ABP group maintained systolic blood pressure (SBP) >80% preoperative values with continuous infusion of norepinephrine, while the control group aimed to keep SBP ≥90 mm Hg using intermittent administration of phenylephrine or ephedrine. The primary outcome was the incidence of postoperative delirium, assessed twice daily using the Confusion Assessment Method (CAM) until hospital discharge. Incidence of postoperative intensive care unit (ICU) admittance was also compared between groups. Quality of life was followed-up via telephone 3 months after surgery using the 3-level version of EuroQol Five Dimensional Questionnaire (EQ-5D-3L). RESULTS: Accumulative time spent under 80% preoperative systolic blood pressure (SBP) values was significantly shorter in goal-directed ABP group than in control group (0 [0–8] vs 12 [0–38] minutes; P < 0.001). Incidence of postoperative delirium was 26.6% (25/94) in the goal-directed ABP group and in 36.2% (34/94) in the control group, with an absolute risk reduction (ARR) of 9.6% (95% confidence interval [CI], −3.6 to 22.8), relative risk of 0.735 (95% CI, 0.478–1.130), P = .162. There was no difference in the incidence of postoperative ICU admittance or quality of life at 3 months follow-up. CONCLUSIONS: Goal-directed intraoperative blood pressure management did not significantly reduce postoperative delirium in older patients undergoing hip fracture repair surgery under spinal anesthesia.
BACKGROUND:Retrospective studies suggest that dexamethasone may provide benefits that extend beyond its antiemetic properties, including a reduction in postoperative complications. However, results from randomized controlled trials have not consistently shown there to be a reduction in composite major adverse events. This discrepancy may be due to confounding factors, measurement error, or simultaneity bias among retrospective investigations. This study used instrumental variable analysis (IVA) to help address potential sources of bias and better estimate treatment effects in patients undergoing total joint arthroplasty (TJA). METHODS:Patients who underwent primary elective TJA between 2016 and 2021 were identified using diagnosis and procedural codes. Bivariate regression, multivariable regression, and IVA were conducted. The primary end point was a 90-day composite (any versus none) of major postoperative medical complications. Secondary outcomes were infection, readmission, and death. Two distinct instruments-the frequency of dexamethasone use by surgeon and by hospital-were used to evaluate the robustness of our IVA. Patient demographics, hospital factors, and comorbidities were reported using descriptive statistics. Instrumental variable covariates were selected using the least absolute shrinkage and selection operator with 3 regularization parameter strategies. RESULTS:1525,844 TJAs performed between 2015 and 2021 were identified (976,996 knees [total knee arthroplasty {TKA}]; 548,848 hips [total hip arthroplasty {THA}]). Major postoperative medical complications were observed in 31,299 (3.43%) dexamethasone-exposed patients compared to 31,266 (4.87%) unexposed patients. Surgeon-based IVA yielded results comparable to the multivariable and bivariate analysis (local average treatment effect [LATE]: TKA: -1.20% [95% confidence interval [CI], -1.33% to -1.08%]; THA: -1.14% [95% CI, -1.30% to -0.99%]). Hospital-based IVA produced similar findings (LATE: TKA: -1.23% [95% CI, -1.38% to -1.09%]; THA: -1.18% [95% CI, -1.35% to -1.00%]). Both instruments demonstrated high F -statistics and significant Hausman tests. Secondary outcomes mirrored these results, except for mortality, which did not meet endogeneity criteria across analyses. CONCLUSIONS:The findings of this study support that dexamethasone exposure is associated with a reduction in composite major postoperative complications after TJA. The observed moderate treatment effect, in conjunction with a low baseline incidence of adverse events, may explain the inconsistent outcomes reported in previous randomized trials. Future prospective studies should incorporate composite end points and target high-risk patient populations or procedural subgroups.
BACKGROUND:Evaluation of the mitral valve during transcatheter edge-to-edge repair (TEER) for management of mitral regurgitation is commonly guided by intraprocedural interventional transesophageal echocardiography (TEE). The risk of iatrogenic mitral stenosis (MS) remains a concern, particularly in patients requiring multiple clips, since the mitral valve orifice area (MVA) is reduced. The value of conventional flow-based echocardiographic methods to rule out MS is limited by intraprocedural and general anesthesia (GA)-induced hemodynamic variability. This retrospective study introduces the novel adaptation of a 3-dimensional (3D) Orifice Area (3DOA) technique to evaluate post-TEER MVA. We evaluated the degree of agreement between MVAs derived via TEE 3DOA, TEE pressure half-time (PHT), and postprocedure transthoracic echocardiography (TTE) PHT with patients awake. METHODS:TEE and TTE images from 20 adult patients with severe mitral regurgitation undergoing a TEER (MitraClip, Abbott) procedure were retrospectively reviewed. MVAs obtained by MTEE 3DOA and TEE PHT under GA were compared to those acquired with TTE PHT with patients awake. Agreement was assessed via calculation of Bland-Altman 95% limits of agreement and Lin's concordance correlation coefficients, both with 95% confidence intervals (CIs). RESULTS:There was good agreement between TEE 3DOA-derived MVA measurements under GA and TTE PHT-derived MVA measurements in awake patients, as reflected by Bland-Altman (lower limit of agreement: -.0.45 [95% CI, -.58 to -.31] and upper limit of agreement: 0.26 [95% CI, 0.12-0.4]), and an excellent concordance correlation coefficient value (0.95 [95% CI, 0.86-0.98]). In contrast, agreement between TEE PHT-derived MVA and TTE PHT-derived MVA was weak, with much broader limits of agreement (lower limit of agreement: -1.6 [95% CI, -2.19 to -1.02] and upper limit of agreement: 1.43 [95% CI, 0.84-2.01]) and a weak concordance correlation coefficient value (0.46 [95% CI, 0.02-0.75]). CONCLUSIONS:In this retrospective cohort study, we demonstrated excellent agreement between TEE-3DOA-derived MVA under GA and TTE PHT-derived MVA in awake patients, but not between TEE versus TTE PHT. These findings warrant further validation in larger patient datasets to assess the utility of 3D echocardiographic approaches in evaluating MVA after TEER.
